Acquired binocular horizontal diplopia

Acute myeloid leukemia presenting as horizontal diplopia

Acute myeloid leukemia (AML) accounts for 16% of all leukemias in children. Prognosis in the pediatric population is better than that of older populations, with a younger age at diagnosis being a favorable prognostic factor [1]. Diplopia is a rare first presenting sign of AML. We present a 15 year old male complaining of diplopia and unilateral orbital swelling. Workup in the emergency department found normal neuroimaging but revealed a markedly elevated leukocytosis with anemia and thrombocytopenia. Peripheral smear showed increased blast cells >10%. This patient was ultimately diagnosed with AML. This case demonstrates an atypical presentation of AML and urges a thorough work up for patients presenting with unexplained diplopia.

Oculomotor abnormalities in a patient with fragile X-associated tremor/ataxia syndrome

We present a case report of an 80-year-old man with Fragile X-associated tremor/ataxia syndrome (FXTAS) and acquired diplopia, strabismus, and other oculomotor abnormalities. This is the first case report of ocular abnormalities in a patient with FXTAS.

Convergence paralysis as a manifestation of polyarteritis nodosa

Polyarteritis nodosa (PAN) is a rare, systemic necrotizing vasculitis of medium-sized arteries. The American College of Rheumatology criteria for the diagnosis of PAN includes at least three of: 1. weight loss < 4 kg, 2. livedo reticularis, 3. testicular pain or tenderness, 4. myalgias, weakness or leg tenderness, 5. mono-or polyneuropathy, 6. diastolic hypertension, 7. elevated blood creatinine or urea, 8. hepatitis B antigen or antibody in the serum, 9. aneurysms or occlusions of visceral arteries or 10. granulocytes on small or medium sized artery biopsy. Common sites of involvement include skin, joints, kidneys, gastrointestinal tract and peripheral nerves. Central nervous system involvement has been reported in up to 40% of cases; the usual manifestations are encephalopathy, focal deficits and seizures. Descriptions of PAN in the pediatric literature has been reported in fewer than 250 children.

Double Vision

When evaluating a patient with a complaint of double vision, it is important to distinguish monocular versus binocular diplopia, which are differentiated by asking the patient to cover each eye separately. In the setting of binocular double vision, one of the two images disappears when either eye is covered, because diplopia is the result of ocular misalignment. On the other hand, monocular double vision resolves when the affected eye is covered, but remains when the opposite eye is occluded. Causes of monocular diplopia include cataract, refractive error, and retinal disease, which can be managed accordingly by an ophthalmologist. However, an unusual form of monocular double vision can occur in the setting of cortical dysfunction. Cerebral polyopia describes the perception of multiple images and arises from an occipital disturbance. It can occur with migraine headaches and can be accompanied by a homonymous hemianopia. Palinopsia refers to the persistence of an image that is no longer in view (visual perseveration or stroboscopic effect) and results from an occipital lesion as well. The exact mechanism of polyopia and palinopsia are uncertain and both conditions are extremely rare. The majority of this discussion will focus on binocular double vision and its management. The main treatment objective of binocular diplopia is to restore the largest area of single binocular vision. Ideally, patients would be able to achieve single vision in all fields of gaze, but this is not always possible. The majority of patients are treated with either prism lenses or eye muscle surgery.